Participant’s Handbook
Module 2
Communicating
Bad News
© EPEC Project, The Robert Wood Johnson Foundation, 1999.
The Project to Educate Physicians on End-of-life Care comes from the Institute for Ethics
at the American Medical Association. Permission to produce for non-commercial,
educational purposes with display of copyright and attribution is granted.
Emanuel LL, von Gunten CF, Ferris FD. The Education for Physicians on End-of-life
Care (EPEC) curriculum, 1999.
Special thanks to the EPEC Team, the EPEC Advisory Group, and all other contributors.
Abstract
Communicating bad news is an essential skill for physicians. This module presents a 6-
step approach to communicating bad news. The steps include getting started, finding out
what the patient knows, finding out how much the patient wants to know, sharing info r-
mation, responding to feelings, and planning/follow-up. Approaches for handling the
family who says “don’t tell” the patient, for using a translator, and for communicating
prognosis are also discussed.
Key words
bad news, communication skills, information sharing, language barriers, planning, re-
sponding to emotion, translators
Objectives
The objectives of this module are to:
• know why communication of bad news is important
• understand the 6-step protocol for delivering bad news
• know what to do at each step of the protocol
• know how to apply the protocol to communicate any news
Introduction
Communicating bad news is an essential skill for physicians. Many of them find it chal-
lenging to convey bad information, especially when this involves a life-threatening
illness. Some feel inadequately prepared or inexperienced. Others fear the news will be
distressing and adversely affect the patient, family, or the therapeutic relationship.
However, the vast majority of Americans want to know if they have a life-threatening
illness. Although legitimate cultural variations are important, breaking bad news in a di-
rect and compassionate way can improve the patient’s and family’s ability to plan and
cope, encourage realistic goals and autonomy, support the patient emotionally, strengthen
Advance preparation
All of the discussion to this point is about preparation to give the bad news. Some of that
preparation might best occur well before the bad news is actually given. The initial as-
sessment, and subsequent discussions that prepare the patient for critical tests, all provide
opportunities to determine what the patient already knows and how he or she would like
to have information handled.
Communicating prognosis
Patients frequently ask about prognosis. There are many motivations for this request.
Some want to have a sense of their future so they can plan their lives. Others are terrified
and hope that you will reassure them that things are not so serious.
Before directly answering their questions about prognosis, inquire about their reasons for
asking. Questions might include:
• What are you expecting to happen?
• How specific do you want me to be?
• What experiences have you had with others with a similar illness?
• What experiences have you had with others who have died?
• What do you hope/dream will happen?
• What is your nightmare about what will happen?
Caregiver communication
The sharing of information among caregivers is critical. Maintain a chart or log book
close to the patient that can be shared by all who provide care, including physicians.
Pooled information can facilitate a continuous plan of care, avoid constant repetition of
questions, and avoid unwanted activities. It will be most effective if the chart or log book
includes goals for care, treatment choices, what to do in an emergency, likes and dislikes,
things to do and or not to do, and contact information for family, physicians, and other
members of the interdisciplinary team. Ensure that data is recorded accurately and acces-
sible to everyone.
Summary
This 6-step protocol for delivering bad news offers guidelines and practical suggestions
on how to communicate any medical information effectively and compassionately, and
respond to a patient’s and family’s feelings and needs. Approaches for handling the fa m-
ily who says “don’t tell” the patient, the use of a translator, and the communication of
prognosis are also discussed. Tips are provided for when language is a barrier, for com-
municating uncertain prognoses, and for coordinating communication among caregivers.
The protocol is a framework for approaching this essential task for physicians and all
other members of the interdisciplinary team. It is not meant to be a rigid set of rules that
Communicating prognosis
14. Inquire why the patient and family are asking in order to have a sense of their context
for the question.
15. Give an accurate estimate of prognosis when requested.
Pearls
1. Sit down.
2. Use a “warning shot;” that is, say something to prepare such as, “I do not have good
news.”
3. Say it, then stop and listen.
4. Have tissues handy.
5. Consider “I would not be surprised if [the patient] died within the next
year/month/week/day” as a way to communicate prognosis.
Potential pitfalls
1. Delivering news in a public place, such as in the hallway.
2. Interruptions. Turn off your pager. Avoid other interruptions.
3. Communicating news over the telephone. Avoid this unless the patient is prepared
ahead of time.
4. Physicians talk too much when nervous, uncomfortable.
Resources
Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Balti-
more, MD: The Johns Hopkins University Press; 1992:65-97.
Faulkner A, Maguire P. Talking to Cancer Patients and Their Relatives. Oxford,
England: Oxford University Press; 1996:58-70.
Field MJ, Cassel CK, Eds. Approaching Death: Improving Care at the End of Life.
Washington, DC: National Academy Press; 1997:59-64.
Quill TE, Townsend P. Bad news: delivery, dialogue, and dilemmas. Arch Intern Med.
1991;151:463-468.
Sim I. How to give bad news. Available at:
http://www.med.stanford.edu/school/DGIM/Teaching/Modules/badnews.html. Accessed
October 23, 1998.